社区老年夫妻慢病协同管理模式构建及效果评价研究

China’s limited community medical resources cannot meet chronic disease prevention and treatment needs of its rapid growing ageing population. The improvement and maintenance of patient’s self-management is essential for chronic disease management. Given disease management occurs in the context of family, this study proposes to develop and validate a Couple Collaborative Management Model of Chronic Diseases (CCMMCD) that integrates the resources of health care professionals and older couples, to enhance couples’ disease management knowledge and skills, and to promote their health and quality of life. Using Type 2 Diabetes Mellitus (T2DM) as an example, the CCMMCD will be developed based on the Dyadic Model of Coping with Chronic Illness and Social Cognitive Theory, in accordance with opinions generated from qualitative group interviews and expert panel reviews. The CCMMCD will then be validated using a cluster randomized controlled trial, whereby 240 T2DM patients aged ≥60 and their partners recruited from 20 community health care centers of Guangzhou, will be randomized into two-equal-sized groups, namely, the couple-based intervention group and the patient-only control group. For the intervention group, both the patient and their partner will receive health education and behavior change training; while these interventions will be provided only to the patient in the control group. Group differences in patients’ hemoglobin A1c, partners’ quality of life and couples’ health behaviors, as well as cost-effectiveness will be compared. This study will promote complementation and interaction between community health care providers and families, as well as generate first-hand evidence of efficiently conducting chronic disease management for community-dwelling older adults.

我国社区卫生资源尚不能满足逐年迅猛增长的老年群体慢病防治需求，改善并长期维持患者自身管理行为是慢病管理的难点。本研究针对慢病管理在家庭进行的特性，旨在建立医护专业支持和伴侣互助的协同管理新模式：对夫妻实施管理，提高协作管理慢病的意识和能力，维护双方健康和生活质量。研究拟以二型糖尿病为例，基于慢病双向应对模型和社会认知理论，结合定性访谈和专家意见构建协同管理模式。采用整群随机对照试验评价模式效果：将广州市20个社区卫生服务中心的240对≥60岁老年糖尿病患者夫妻，以中心为单位随机等分为夫妻协同干预组和仅干预患者对照组，实施健康教育和行为改变干预，并比较两组患者糖化血红蛋白、配偶生活质量、双方健康相关行为等指标和管理成本效益的差异。本研究将夫妻影响依赖关系有机整合到社区慢病管理服务体系中，为促进社区卫生与家庭资源互补互动，高效开展老年群体慢病防治提供科学依据。

我国社区卫生资源尚不能满足逐年迅猛增长的老年群体慢病防治需求，改善并长期维持患者自身管理行为是慢病管理的难点。本研究以二型糖尿病为例，基于慢病双向应对模型和社会认知理论，结合定性访谈和专家意见构建了协同管理模式，并采用随机区组对照试验评价模式效果：把广州市14个社区卫生服务中心的207对≥55岁老年糖尿病患者夫妻在每个中心以1：1的比例随机分为基于夫妇的干预组和基于个体的对照组，实施1个月的小组健康教育和2个月的行为改变干预（电话干预），并比较两组患者糖化血红蛋白、配偶生活质量、双方健康相关行为等指标的差异。结合突发的新冠疫情，研究进一步针对疫情对项目实施及患者健康管理影响进行了调查。研究结果显示，干预组患者的糖化血红蛋白改善较对照组好，但在6月随访期间尚无统计学差异；两组的糖尿病管理效能、糖尿病自我管理行为、运动干预后均升高，脱离干预后均下降，但干预组下降较对照组更缓慢；干预组配偶的躯体健康有改善的趋势，而精神健康有变差的趋势。疫情调查发现，男性的健康行为更不容易受疫情影响，干预组对于疫情冲击具有保护作用，且女性患者更受益于干预带来的保护作用；距离疫区越远，患者糖尿病自我管理行为越弱，说明疫情爆发会提高糖尿病患者对于自我管理的重视；女性协同能力高于男性，但距离疫区越远，不同性别在协同能力上的差别越小。夫妻协同管理模式在维持患者的行为改变上有重要意义，并且对突发公共卫生事件如新冠疫情的影响可以起到一定的缓冲作用。本研究为促进社区卫生与家庭资源互补互动，高效开展老年群体慢病防治提供了科学依据。

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